And now, on to the fun stuff. DKA is a complication from diabetes; its underlying causes may be concomitant infection, missed insulin treatments, or newly diagnosed, previously unknown diabetes. How can you tell when someone is experiencing DKA? Here's a partial list of symptoms: dry skin, labored breathing, dry mucous membranes, decreased skin turgor (i.e. the skin begins to look saggy), and decreased reflexes. People with DKA typically experience the ketotic (fruity) breath, confusion, abdominal pain, and, in extreme cases, a coma. In order to treat DKA, one must address the body's aberrant functions; the patient needs to rehydrate, reverse the acidosis and ketosis, reduce plasma glucose concentration, and replenish electrolytes. Somehow, this seems a little more complex than shooting some Novalin and chugging a Gatorade. Indeed, treatment is usually a combination of an antihyperglycemic agent to lower plasma glucose and ketone levels (your insulin shot), a mineral solution like potassium chloride, which moves potassium out of cells (reversing ketosis), along with intense observation at your local hospital, as the rehydration typically throws a patient's potassium levels into flux, which could lead to further metabolic complications.
That our erstwhile serial killer was able to run around in a state of sustained ketoacidosis, apparently without it impairing his ability to woo Kari Wuhrer or execute complex schemes on a tight schedule, suggests one of the following: there are some things modern medicine can't explain; there are some things the episode could have handled better; or we have proof that in addition to their masterful command of time management, serial killers also have the ability to regulate their metabolisms. I'll leave that call to you.
Meanwhile, back in this week's episode, Gil's now working the entire crime scene, going over the entire underpass area and noting things like a bloodstained rock. He then walks back over to the shopping cart and begins poking under the blanket; he finds a red nylon Kate Spade bag. Curious, he opens it and pulls out a Day Runner, then peers in the bottom of the bag. There are several syringes in there.
Cut to Gil and David the Somber Coroner standing over the body. Gil inquires as to whether or not the woman used drugs; David replies, "No track marks. Tox screen came up empty except for botulin." Across America, women instantly say, "Botox." Gil wonders if it's food poisoning; David replies that he'll know more when he cuts open her stomach. So that rat got in elsewhere? (I had thought that perhaps the rat had gnawed its way through her entrails and followed her esophagus to her mouth, but that's because I was somehow attributing both a basic knowledge of human anatomy and a modicum of logic to an animal with a brain the size of a Pez candy. I should reevaluate my own cranial capacity.) Anyway, David says to Gil, "Heard about the rat? Hope he didn't have any children." I'm thinking we have a case of pronoun confusion here; unless David's concerned that the rat has someone left behind a tiny rodent summons to pay child support, there's no chance of a male rat leaving behind a litter. Anyway, Gil gives David a sympathetic grimace that speaks volumes. David invites Gil to take a look at the tiny puncture wounds in the dead woman's forehead, and tells him that they indicate repeated injections -- "You sure she's homeless?" he tries to confirm. Gil replies, "Sometimes, I'm not sure of anything." David then confirms what we've all suspected: "My guess: beautification. She was injected with pig botulism -- Botox. The ultimate wrinkle cream." The TMICam shows up and demonstrates how a syringe plunges into the skin and releases its load of nerve-freezing goodness. Gil wants to know how the botulin got into her bloodstream; David replies, "Bad doctor. Missed the muscle and shot directly into her supratrochlear vein." As he explains this, his finger traces the vein's path. Gil replies, "Amazing -- the advances we make in science and the primitive uses we find for them."